buckling stress. Areas tested on each foot include the metatarsal heads of the first, third, and fifth toes, the end of the first toe and the end of the third toe, staying away from wounds or callouses. This type of sensory testing is a screen for determining if the older adult has at least protective sensation on the soles of the feet and can trigger a more in depth sensory examination if 6 or less of the 10 areas tested display normal sensation (Migliarese, 2017). Figure 4. Monofilament Testing
3. Have the patient stand. 4. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in blood pressure of 20 mm Hg or more, or in diastolic blood pressure of 10 mm Hg or more, or experiencing lightheadedness or dizziness is considered abnormal (CDC/ STEADI, 2017). Therapists should also note use of medications for cardiovascular conditions, such as hypertension, arrhythmias, or other types of pharmacologic agents that could influence blood pressure or heart rate response to exercise. Cognition Screening and medical tests can be used to assess signs and symptoms consistent with cognitive decline and can include some of the following screens: ● Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975; Kurlowicz & Wallace, 1999). ● Mini-Cog test (Borson, Scanian, Brush, Vitaliano, & Dokmak, 2000). ● St. Louis University Mental Status Examination (SLUMS; Morley & Tumosa 2002). ● Clock Drawing Test (CDT; Lorentz, Scanlan, & Borson, 2002). ● Short Blessed Test (Brooke & Bullock, 1999). ● Verbal Fluency Tests (Canning, Leach, Stuss, Ngo, & Black, 2004). ● Animal Naming Test (Howe, 2007). ● Montreal Cognitive Assessment (MoCA; Nasreddine et al, 2005). The most well-known screening exam for cognitive decline is the MMSE. The MMSE takes 10 to 15 minutes to complete, as does its alternative test, the St. Louis University Mental Status Examination (SLUMS). The Mini-Cog test is a 3-minute instrument used to screen for cognitive impairment that includes a three-item recall, interrupted by the Clock Drawing Test (CDT) where the individual draws the time on a blank circle representing a clock face. The Mini-Cog is less influenced by education or socioeconomic status and uses a simple scoring system (Borson et al., 2000). The Short Blessed Test, verbal fluency, and animal naming tests are brief screening tools that can detect changes in cognition. The verbal fluency test is a simple screening tool. The examiner asks the participant to name as many words as possible that start with the letters F, A, or S in 60 seconds. Participants can’t use words with same stem like friends, friendly, friend. Normative data depends on education and age, but in general, adults ages 60 to 79 years should be able to name 25 to 42 words, whereas adults age 80 to 95 years should be able to name 22 to 37 words. Scores increase as education increases (Tombaugh, Kozak, Rees, 1999). A screening tool that is less biased by education is the animal naming test. For this tool, the examiner asks the participant to name as many animals in 60 seconds as possible without repeating. The animal names are recorded for accurate measurement and to check for repeats. A general cutoff is that fewer than 15 animals named indicates cognitive impairment. Additional normative data for the sixth decade of life is 17 animals, seventh decade is 16 animals, the eighth decade is 14 animals, and adults over 90 years of age should be able to name at least 13 animals (Tombaugh et al., 1999). The Montreal Cognitive Assessment (MoCA) is a newer 30-point one-page test that can be completed in 10 minutes (Nasreddine et al, 2005). Cognitive demands due to any of the potential age-related cognitive declines can result in delays in balance reaction times, muscle response, and amplitude of force generation during dual-task postural activities. Difficulties are more significant in balance-impaired and cognitively impaired older adults than in healthy, successfully aging older adults.
Note . From Western Schools, 2019. Figure 4 shows the areas to test on the soles of the feet. Vestibular deficits may manifest themselves in performance on the mCTSIB, difficulty with head turns during gait, or by complaints of dizziness. Peripheral vestibular hypofunction is a common problem in older adults, making it important to assess this system in more detail for those who complain of dizziness, unsteadiness, or lightheadedness. Older adults may not use these terms to describe “dizziness” or even realize that these types of sensations are not a part of normal aging. Adults who perform poorly on the mCTSIB, have unsteady gait with head turns, or who have complaints that indicate dizzy sensations with head movements should undergo a thorough vestibular evaluation by a clinician with expertise in this area. Dual-tasking Additional neurologic assessments should investigate the ability to dual-task during gait, especially if the clinician suspects cognitive decline that may affect mobility. Older adults show deficits in motor tasks when challenged to perform more than one activity at a time. Research has demonstrated that deterioration in gait during dual-task testing compared with single-task performance is associated with increased fall risk (Muir-Hunter & Wittwer, 2016). However, at this time, evidence is lacking that could recommend which dual-task testing procedures should be used in clinical practice. Commonly used dual-task exams are the TUG Cognitive Test (TUG cog) and the TUG Manual Test (TUG man). For the TUG cog test, individuals are given verbal instructions to stand up from a chair, walk 3 m as quickly and safely as possible, cross a line marked on the floor, turn around, walk back, and sit down. This is timed as the person counts backward by threes from a randomly selected number between 20 and 100 (Maranhao-Filho, Maranhao, Lima, & Silva, 2011). For the TUG man, individuals must follow the same instructions for walking as in the TOG cog, but instead of counting backward they hold a cup filled with water (Hofheinz & Schusterschitz, 2010). If a walker is required for safe gait, then the manual task may be difficult to execute. Vital signs and cardiovascular exam A thorough fall risk evaluation also should include examination of the cardiovascular system. The cardiovascular exam should include checking heart rate and rhythm, postural pulse, and orthostatic hypotension which is a risk factor for falls. Adults who describe feeling lightheaded with changes in positions should be evaluated for orthostatic hypotension. The STEADI site includes a printable assessment handout for orthostatic hypotension (https://www.cdc.gov/steadi/pdf/STEADI-Assessment- MeasuringBP-508.pdf), which includes the following instructions: 1. Have the patient lie down for 5 minutes. 2. Measure blood pressure and pulse rate in supine.
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